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Full text of "United States Navy Medical News Letter Vol. 27, No. 9, 4 May 1956"

NavMed 369 




^ r ^ , 

UNITED STATES NAVY 





Editor - Captain L. B. Marshall, MC, USN (RET) 



Vol. 27 



Friday May 4, 1956 



No. 9 



TABLE OF CONTENTS 



Voluntary Retirement 2 

Blood Loss and Operative Time in Surgical Procedures 3 

Recurrent Anterior Dislocation of the Shotilder 5 

Fracture of the Odontoid Process 7 

Polytheylene Glycol Ointment in Burn Treatment 8 

Enzymes and Wetting Agents in Treatment of Pulmonary Atelectasis .... 10 

Effect of Pregnancy on the Course of Heart Disease 12 

Palliation of Ovarian Carcinoma with Phosphoramide Drugs 14 

Methods of Prevention and Control of Dental Caries 16 

Revised Dental Standards for Entrance to Officer Candidate Training. ... 18 

From the Note Book 20 

Recent Research Projects 23 

Postgraduate Course Offered to Medical Officers 24 

Liaison with Public Health Service (BuMed Inst. 6200. 2A) 25 

Poliomyelitis Vaccine (BuMed Notice 6230) 25 

Recurring Reports, Review of (BuMed Notice 5213) 26 

NavMed HC- 3 Card, Modification of (BuMed Notice 1080) . 26 

Histopathology Centers (BuMed Inst. 6510. 5A) 26 

Outpatient Report, DD Form 444 (BuMed Inst. 6320. 9C) 27 

Treatment Furnished Pay Patients (BuMed Notice 6320) . . 27 

DENTAL SECTION 

Advanced Residency Training . 28 American Society of Oral Surgeons, 29 

Remnants and Records 29 Dental Service at USNH Memphis. . . 30 

Naval Dental Activities 29 Revised Dental Standards 30 

MEDICAL RESERVE SECTION 

Military Medicine Section AMA . 31 Check Your Promotion Points 31 

PREVENTIVE MEDICINE SECTION 



Poliomyelitis Vaccine 32 

Swimming Pool Sanitation .... 34 



"Passage to Freedom" 35 

Examinations of the Low Back ... 39 



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Medical News Letter, Vol. 27, No. 9 



Policy 

The U. S Navy Medical News Letter, is basically an official Medical 
Department publication inviting the attention of officers of the Medical De- 
partment of the Regular Navy and Naval Reserve to timely up-to-date items 
of official and professional interest relative to medicine, dentistry, and 
allied sciences. The amount of information used is only that necessary to 
inform adequately officers of the Medical Department of the existence and 
source of such information. The items used are neither intended to be nor 
are they susceptible to use by any officer as a substitute for any item or 
article in its original form. All readers of the News Letter are urged to obtain 
the original of those items of particular interest to the individual. 

Notice 

Due to the critical shortage of medical officers, the Chief, Bureau of 
Medicine and Surgery, has recommended, and the Chief of Naval Personnel 
has concurred, that Reserve Medical Officers now on active duty who desire to 
submit requests for extension of active duty at their present stations for a 
period of three months or more will be given favorable consideration. BuPers 
Instruction 1926. IB applies. 

iff )^ )ffi iff ilfi J): 

Voluntary Retirement 

The policy of the Bureau of Medicine and Surgery is to recommend 
approval on requests for voluntary retirement of medical officers who have 
20 or more years' active service creditable for retirement. However, be- 
cause of personnel shortages, the Bureau may of necessity have to recom- 
mend modification of the requested effective date because it may not always 
be possible to furnish a qualified relief by the time specified in the request. 
(PersDiv, BuMed) 

# # 4: 3je 4: >!: 

Change of Address 

Please forward requests for change of address for the News Letter to: 
Commanding Officer, U.S. Naval Medical School, National Naval Medical 
Center, Bethesda 14, Md, , giving full name, rank, corps, and old and new 
addresses. 



Medical News Letter, Vol. 27, No. 9 
Blood Loss and Operative Time in Surgical Procedures 



3 



The deliberate reduction of arterial blood pressure during major opera- 
tive procedures has been alleged to provide an essentially bloodless surgical 
field, thereby minimizing blood loss and decreasing operative time. This 
report compares results obtained in 90 patients during general surgical pro 
cedures, and in whom the blood pressure had been deliberately lowered 
with 84 patients with similar operations without hypotension. All patients 
were hospitalized during the same period of time and were matched so far 
as type of operation and skill of the surgeon were concerned. 

The types of operations for which deliberate hypotension was provided 
included radical dissections of the neck, 29; radical dissections within the 
pelvis, 17; radical mastectomies or mastoplasties, 7; radical dissection of 
the groin, 6; and other operations of similar magnitude such as Whipple's 
resections for carcinoma of the pancreas, excision of cranial tumors, shoul- 
der disarticulation, abdominal perineal resection, et cetera. 

The techniques for producing hypotension are listed in a table. 

It is apparent from the data presented that hypotensive anesthetic tech- 
niques reduce the amount of blood lost during major operative dissections. 
It is difficult to determine whether such reduction is of sufficient degree to 
justify the hazard involved. In both of the series of radical dissections ana- 
lyzed, the reduction was approximately 35%. This represented one unit 
(550 ml. ) of blood saved in the dissections of the neck and two units in the 
dissections within the pelvis. However, it remained necessary to transfuse 
two units in the first instance and four units in the second. 

One of the hazards of any radical dissection is the need for multiple 
transfusion with the possibility of the development of bleeding tendencies. 
In patients with operations similar to those discussed, and operated upon 
without deliberate hypotension, three deaths occurred from exsanguination 
due to uncontrollable oozing following multiple transfusion. Is a reduction 
in needed transfusion of blood from six units to four units a significant safety 
factor in this regard? The authors are unable to answer this question defin- 
itely, but doubt that an affirmative answer is justified. 

Deliberate hypotension does not guarantee a reduction in blood loss. 
Some surgeons have commented that occasionally patients demonstrate more 
oozing at the lower blood pressure than at the higher pressure. However, 
in general, less scatter is noted in the hypotension groups as compared with 
the control groups. 

It is difficult to compare blood loss in different groups of patients for 
several reasons. First, the patients compared must be hospitalized within 
the same period of time. If a comparison were drawn between the deliberate 
hypotensive group reported herein and the group operated upon with standard 
anesthetic techniques reported by Royster et al. , several years ago, hypo- 
tension would appear very desirable. However, when the patients of 1951 



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Medical News Letter, Vol 27, No. 9 



are compared with the control group of this report, it becomes obvious that 
the same group of surgeons have reduced their operative time significantly 
as well as the blood lost at operation. A second source of confusion, when 
comparisons are drawn for this type of surgery, are such variables as the 
extent of operation, condition of the patient's tissue, and degree of arterio- 
sclerosis. To. rule out these variables, a much larger series of patients 
than reported in this presentation would be needed. 

It is of interest that the operative time was not reduced by the use of 
hypotension. This would suggest that blood loss did not normally hamper 
surgical dissection of this type. 

Deliberate hypotension is not employed without considerable risk to 
the patient, The production of deliberate hypotension is a formidable pro- 
cedure. It should be undertaken only by those trained in the use of the tech- 
nique and those fully cognizant of the physiology of hypotension, the pharma- 
cology of the drugs used to produce hypotension, the adjtincts assisting to 
induce hypotension, and the limits of the method. Neither spinal anesthesia 
nor the ganglionic blocking agents are consistently effective in producing 
hypotension. 

The ganglionic blocking agents appear to reduce the need for general 
anesthetics, and also reduce pulmonary ventilation by a "curare-like" action. 
Failure to lighten the plane of anesthesia or to provide adequate tidal exchange 
during hypotension may lead to disaster. Lack of knowledge of the duration 
of effects of ganglionic blocking agents may increase morbidity and mortality. 

The authors currently utilize deliberate hypotension with less enthusi- 
asm than 18 months ago. Although the surgeons initiate the request for 
hypotension, they note little resistance when they are reluctant to deliberately 
lower the blood pressure. Candidates for the techniques are carefully select- 
ed, and must be free of all complicating cerebral, renal, hepatic, or cardio^ 
vascular disease. Despite the data presented, a few surgeons believe that 
controlled hypotension facilitates dissection. While these data neither favor 
deliberate hypotension nor disprove the value of the technique, they do call 
for objectivity in determining the ultimate role of the method in surgery. 

Data and conclusions obtained from the use of deliberate hypotension 
in 90 patients have been presented and compared with those noted in control 
groups. 

Blood loss was found to average 910 ml. in 29 patients who had radical 
dissections of the neck utilizing deliberate hypotension, and 1415 ml. in 20 
control patients. The average operative time was 4 hours and 45 minutes 
with controlled hypotensioUj and 3 hours and 50 minutes without hypotension. 

In 17 patients, who had radical dissection within the' pelvis with induced 
hypotension, the blood loss averaged 1870 ml. , and in 11 control patients, 
the average loss was 2805 ml. The average operative time was 5 hours with 
deliberate hypotension, and 4 hours and 35 minutes in the controls, (Ditzler, 
J- W. , Eckenhoff, J. E, , A Comparison of Blood Loss and Operative Time 



Medical News Letter, Vol, 27, No. 9 5 



in Certain Surgical Procedures Completed With and Without Controlled Hypo- 
tension: Ann. Surg., 143j 289-293, March 1956) 

3^ j^f ^ ^ jjt Sjc 

Recurrent Anterior Dislocation of the Shoulder 

Although recurrent dislocation of the shoulder is one of the oldest recog- 
nized orthopedic entities and has been the subject of voluminous writings, 
indicating continual interest, practically every phase of the lesion remains 
controversial today. It might be said that there is agreement on only two 
aspects of the lesion, namely, the clinical manifestations and the clear-cut 
indication for operative treatment. 

A patient usually considers an injury to be the cause of the recurrent 
dislocation. The typical history is that of a young adult, usually a healthy 
and muscular man, who sustained a traumatic dislocation of the shoulder 
while participating in some sport. The dislocation was reduced and the shoul- 
der functioned normally for a few months when a second dislocation occurred, 
in some cases under circumstances similar to those of the initial episode, 
but usually in consequence of some insignificant trauma. Thereafter, recur- 
rence took place with varying frequency. In long-standing cases, slipping 
may have occurred while the patient turned in sleep, or the shoulder may 
have repeatedly dislocated on any ordinary movement that involved abduction 
and external rotation of the arm, such as putting on a coat or combing the hair. 
The writer has observed that, in his experience, whenever two recurrences 
have been sustained, there are subsequent episodes. 

Little actual discomfort is experienced when the shoulder dislocates, 
and the patient himself may be able to force the humeral head back into place. 
Nevertheless, the lesion represents real disability. Rest may be disturbed. 
The patient may hesitate to carry out some of the common functions of daily 
living. Even when the humeral head tends to subluxate, rather than to dis- 
locate completely, the patient is harassed and obsessed by the fear of total 
displacement. A young athlete is particularly handicapped by the lesion, and 
a man earning a livelihood suffers a considerable loss of working capacity. 

By the time the patient is first seen there is little on which the surgeon 
can base the diagnosis except the history of acute traumatic dislocation fol- 
lowed by recurrences. Examination of the shoulder produces little in the way 
of objective signs. Routine roentgenographic examination sometimes demon- 
strates a groove in the humeral head provided that it is well defined. Special 
projections must be made to visualize smaller defects as well as pathologic 
changes in the anterior glenoid margin. 

Innumerable operations have been described for the repair of recurrent 
dislocation and new procedures and modifications of older methods continue to 



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Medical News Letter, Vol 27, No. 9 



to be proposed. However, reports appearing within the past 7 years, indicate 
that operative treatment is being confined for the most part to relatively few 
procedures . 

Five different operative methods are in popular use. French surgeons 
have continued to favor the coracoid buttress operation, introduced by Oudard, 
which aims at creating a bone block to prevent exit of the humeral head and 
shortening of the subscapularis tendon. 

In Germany, and particularly in the Scandinavian countries, surgeons 
remain faithful to the Eden-Hybbinette bone block type of operation. This 
procedure consists of reconstructing the damaged glenoid margin by im- 
planting a bone graft into its anteroinferior surface at the site of dislocation. 
Critici sm of this method has been the difficulties of technique, the danger of 
absorption or non union of the bone graft and postoperative restriction of mo- 
tion as well as pain. 

More statistical data have been reported on end results of this procedure 
than of any other method. A series of 773 cases treated with the Eden-Hyb- 
binette method or by a modification has been compiled from literature appear- 
ing in the ID-year period from 1944 to 1954. Dislocation recurred in 55 cases 
(7%). 

In Anglo-Saxon countries, the operations of Magnuson and Stack, Putti 
and Piatt, and Bankart, or modifications of these procedures are considered 
the most effective methods. Each of the procedures has been supported by 
successful end result studies. All three operations have as the common 
objective,, control of the external rotational movement of the shoulder. This 
is accomplished in the Magnuson technique by transferring the insertion of 
the subscapularis muscle from the lesser to the greater tuberosity, shorten- 
ing both the muscle and the anterior capsule. The Putti-Platt technique 
combines imbrication of the anterior portion of the capsule with shortening 
of the subscapularis muscle. A postoperative limitation of the external rota- 
tional movement has not infrequently been mentioned as a disadvantage of both 
of these methods. 

The Bankart operation, based on the recognition of the detachment of 
the glenoid labrum and anterior capsule as the underlying pathologic lesion, 
is directed to the reattachment of the fibrocapsular segment to the glenoid 
rim. Both the Magnus on -Stack and Putti-Platt operations are considered to 
be somewhat easier than the Bankart method in that the technique is less com- 
plicated and inspection of the joint is not required. However, the Bankart 
method has stood out prominently from all other procedures in recent years 
and has been widely used. 

A description is given of the Bankart technique in which the step of 
suturing the glenoid labrum in place, long recognized as a difficult process, 
is simplified by the use of metal staples. 

Personal experience in treating recurrent dislocation over a period of 
many years is recounted. A report is given on 13 cases in which the Bankaxt 



Medical News Letter, Vol. 27, No. 9 



7 



operation, simplified by using staples for fixation purposes, was used. Twelve 
of the thirteen patients obtained excellent results; no recurrence has been 
experienced and the shoulders have good function. (MacAusland, W. R. , 
Recurrent Anterior Dislocation of the Shoulder; Am, J. Surg. , 91 :323-330, 
March 1956) 

9(1 4: it; 3}: :t: t 

Fracture of the Odontoid Process 

Fracture of the odontoid process has in the past been considered an 
uncommon lesion with a discouragingly high fatality rate. 

Many odontoid fractures, as well as other injuries of the upper cervical 
spine, remain overlooked. In conventional roentgenograms of the neck, teeth, 
mastoid processes, and base of the skull sometimes obscure details of the 
atlas and axis. Initial films may be poor owing to the inability of the patient 
to cooperate because of confusion or pain due to cerebral or other injuries. 
Many such patients, admitted in stupor, do not complain of neck pain and are 
hospitalized for treatment of other serious traumatic disorders, with cervical 
fracture either tmsuspected or relegated to a position of secondary importance. 

The commonest complaint was painful stiff neck following a head injury. 
Hospitalization was almost always necessary because of this or associated 
trauma. Severe pain in the neck or suboccipital region was generally felt 
immediately after the accident, although on a few occasions the onset was 
delayed, sometimes as much as 24 hours. Some did not complain because of 
stupor or other post traumatic disorders. 

Examination revealed marked nuchal rigidity, and most patients object- 
ed strenuously to any motion of the head. Soft-tissue swelling in the lateral 
or posterior neck was occasionally found, but was not always localized to the 
upper neck. The site of maximum tenderness also varied in location. 

Although the possibility of odontoid fracture was often considered after 
the initial examination, the diagnosis was not established in any case until 
x-rays were obtained. It was often necessary to repeat films before demon- 
strating a fracture, and planigrams were made if conventional roentgenograms 
were inconclusive. 

Emergency treatment of odontoid fracture and other atlantoaxial lesions 
requires fixation of the head and neck in neutral position and prompt hospital- 
ization. Dislocation must then be reduced by traction and the fracture site 
immobilized to permit healing and prevent additional spinal cord damage. 
Respiratory embarrassment may necessitate tracheotomy, care in a respira- 
tor, or both. Infection at the fracture site should be combated by antibiotics. 

In the presence of more than slight dislocation, traction in tongs is 
generally indicated, but for a child or a patient with a laceration of the scalp 
a head halter may be desirable. Five to seven pounds of pull in tongs are 



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Medical News Letter, Vol, 27, No. 9 



usually enough to reduce dislocation and, thereafter, should be maintained 
at least 2 weeks before the patient is placed in a collar. More than 4 pounds 
of pull in a halter is usually not tolerated for more than a few days because of 
resultant soreness in soft tissues over the chin or reaction in the temporo- 
mandibular joint Four to six weeks of bed rest in all cases, including those 
without dislocation, is desirable. The authors are in general accord with 
the recommendations of Grogono that in the case of older persons, especially 
where disability is minor, a plaster collar alone may be sufficient, but skel- 
etal traction should be instituted in the presence of severe displacement. 
Watson-Jones also believed results of treatment with a cast might be excellent 
and advised operative fusion only if the closed treatment was unsuccessful. 

A few authors have given specific advice as to the duration of immob- 
ilization. Hambly believed that bony union, following fracture of the odontoid, 
might occur in 3 months and advised that a collar be worn for an additional 
month. Osgood and Lund recommended immobilization in plaster for 3 months 
and a Thomas collar for 3 more months. 

It is generally agreed that operative fusion is at times indicated. It 
would seem best to reserve such surgery for those cases with instability at 
the fracture site following a trial of traction and immobilization . The authors 
advise treatment in a collar for as long as 9 months after the fragments are 
approximated before deciding that the fracture will not heal. If redislocation 
takes place, or serious neurological dysfunction appears during this time, 
orthopedic consultation is indicated and surgery should be considered. Treat- 
ment must, however, be individualized according to the severity of the injury 
and the complications encoiintered, e.g. , marked instability at the atlanto- 
axial joint, observed during the first few weeks, may make immobilization 
by traction and plaster jacket alone unusually hazardous. (Amyes, E. W. , 
Anderson, F. M. , Fracture of the Odontoid Process : Arch. Surg., 72: 
377-387, March 1956) 

Polyethylene Glycol Ointment in Burn Treatment 

The care of the burn wound plays a prominent part in the therapy for the 
burned patient. The ideal therapy has not yet been achieved. The immediate - 
goal of such therapy is to effect complete autologous epithelization of the 
wound as rapidly as possible, and while so doing, to protect the patient from 
invasive infection. Part of the difficulty lies in the hope to find a substitute 
for the skin which has been lost without knowing all the functions that this 
substitute should perform. Some of the known criteria for such a substitute 
follow: 

1. It must minimize infection. 

2. It must be nonirritating locally and nontoxic systemic ally. 



Medical News Letter, Vol. 27, No. 9 



9 



3. It must not interfere with epithelization 

4. It must avoid maceration. 

5. It must be economical. 

6. It should avoid multiple dressing changes with their attendant 
trauma and risk of anesthesia. 

7. It should act as a debriding agent, 

8. Sterile precautions should be unnecessary. 

9. It should be useful under varying climatic conditions. 

10. Refrigeration of the agent should be unnecessary; this would 
facilitate stockpiling. 

11. It should be easily applied. 

12. It should keep the eschar soft, thus allowing motion without 
cracking. 

13. It should mimmize pain. 

14. It should be easily adaptable to mass casualties in the event of 
military or civilian disaster. 

15. It should allow easy transportation of the patients without hiding 
the wound. 

These criteria make it clear why many agents have, been tried in the 
past and have been foxind unsatisfactory. 

Nontoxic water-soluble ointments are relatively new in the treatment 
of burns. Water miscible ointments, together with a wetting agent and pyruvic 
acid, have been advocated by Harvey. Polyethylene glycol, related compounds, 
and K-Y jelly have been used rather successfully with pyruvic acid or with 
antibacterial agents. The authors believe that some of the water-soluble 
ointments can, with the addition of secondary agents such as antibiotics and 
debriding agents, fulfill many of these criteria for an ideal burn ointment. 

Throughout the past two years, the authors have treated a series of 
patients by the application of an ointment to exposed burns. This ointment 
consists of a water-soluble base to which has been added antibiotics, fungi- 
cides, and a debriding agent. Polyethylene glycol compounds constitute the 
main vehicle. 

The ointment is applied generously to the wound after the systemic 
needs of the newly admitted patient have been satisfied. It is applied either 
with the gloved hand or by a commercially available dough extruder. The 
latter cooking utensil is very satisfacotry, especially in children, because it 
extrudes a ribbon of ointment which is thus applied atraumatically. The oint- 
ment should be reapplied as often as is necessary to keep the eschars soft. 
This may require application at 4- to 6-hour intervals, depending upon the 
temperature of the environment. The melting point of the ointment may be 
raised or lowered by increasing or decreasing the concentration of the poly- 
ethylene glytol {molecular weight 4000). 

The ointment may be kept (covered) at the bedside without refrigeration. 
Because it contains no water, the antibiotics do not deteriorate. 



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Medical News Letter, Vol. 27, No. 9 



The purpose in reporting these data is to encourage the use by others 
of a water soluble ointment in the treatment of burns by exposure. These 
data are submitted for analysis to lend support to such encouragement. It 
is fully realized that a given mode of burn therapy is difficult to evaluate in 
view of the large number of variables present in the care of a given series. 
However, the net result of the present series has, for the given reasons, 
been so satisfactory it is considered worthy of report. A more critical eval- 
uation of this ointment could be obtained in the future by using control areas 
such as a leg or an arm with burns similar in extent and severity in the same 
patient for comparison. The control areas might be treated by petroleum 
jelly pressure dressing or by exposure therapy without ointment. Comparison 
with burns treated by exposure would be of particular value because, as des- 
cribed by Artz and associates, such therapy fulfills many of the given criteria. 
In the present series, it was elected to first evaluate the general systemic 
response and the over all results of this mode of therapy. This preliminary 
report describes that effort. It is believed, however, that the next step in 
evaluation should consist of a critical comparison with control regions in the 
same patient. 

If the results of this type of therapy are evaluated oh the basis of the 
criteria listed for an ideal ointment, it is apparent that the value of the oint- 
ment as a debriding agent and as an analgesic is impossible to determine 
because there are no controls. The value under varying climatic conditions 
has not been determined. Whether this ointment would allow easy transpor- 
tation of the patients without hiding the wound is diffictilt to state. Certainly, 
the relatively benign course, in spite of the lack of sterile precautions, suggests 
that burns so protected by ointment might withstand the contamination of ordinary 
transportation. Aside from these criticisms, however, it appears that most of 
the demands of the criteria are satisfied under the conditions observed in this 
series. 

An evaluation of experience with a water-soluble ointment in 24 patients 
with burns treated by exposure has been presented. The experience has been 
gratifying and, in the opinion of the authors, warrants further use. (MacGregor, 
C. A , Pfister, R, R. , The Use of Polyethylene Glycol Ointment in Burns 
Treated by Exposure: Surgery, 39:557-563, April 1956) 

Enzymes and Wetting Agents in Treatment 
of Pulmonary Atelectasis 

In April 1953, because of the serious problem of atelectasis in polio- 
myelitic patients, a study on atelectasis was begun at the Rancho Amigos 
Respiratory Center for Poliomyelitis. One hundred and twenty-five cases 
of atelectasis with only one failure are reported in this study. 



Medical News Letter, Vol. 27, No. 9 



11 



The problem of atelectasis is not a new one and for many years has 
been a significant complication in postoperative abdominal general surgical 
cases. Eecently, it has been noted that, in postpoliomyelitic patients, atelec- 
tasis is the most serious complication and the main cause of piilmonary disease 
which leads to death. 

Four factors are prominent in the development of atelectasis: (1) dimin- 
ished respiratory function; (2) absent or ineffective cough; (3) abnormal bron- 
chial secretions, both in quantity and in quality, and (4) respiratory infection. 
Although the etiology of the four factors is far different in poliomyelitic cases 
than others, the common denominator in all atelectasis is the retention of 
viscid tenacious secretions which cause obstruction of the airway to a whole 
lung, a lobe, or a segment. Removal of these secretions, then, is the solu- 
tion to the problem. This has not been easy to accomplish because of the 
extreme viscidity of the secretions in most instances, thereby rendering it 
impossible for the patient to expel the obstructing material. Once the secre- 
tions are thinned or liquefied, expulsion can be accomplished with facility. 

It became obvious that some agent was necessary to thin out and loosen 
these tenacious secretions. The authors turned to the enzymes and wetting 
agents to find the solution. 

Once the secretions are liquefied, the next important step is their 
removal. In atelectasis, these secretions are found not only in the major 
bronchi, but in the majority of instances, obstructing the smaller bronchi, 
bronchioles, and alveoli. Removal of the secretions from these areas in the 
lung is an important factor. In non -poliomyelitic patients, this is accom- 
plished by inducing the patient to cough by whatever means is found necessary. 
Only by an adequate cough can these secretions be removed, no matter whether 
a tracheotomy is present or not. A catheter can reach only secretions in the 
trachea, mainstem bronchi, or even down to the tertiary bronchi, but no 
further. In the post -poliomyelitic patient, coughing becomes an extremely 
complex problem. Most severe poliomyelitic patients have no cough, or one 
which is completely ineffective. Thus, they must be coughed artificially. 

All patients in this study had definite atelectasis by x-ray film and all 
reported as clear showed complete clearing by x-ray. The only enzyme used 
was aerosol "tryptar" and the only aerosol wetting agent used was "triton 
A-20, " a 25% solution of "alevaire, " which is an aqueous solution of a new 
detergent, "triton WR-1339, " 0. 125%, in combination with sodium bicar- 
bonate 2% and glycerin 5%. 

Three methods were used in administering "tryptar": (1) by direct 
instillation through a bronchoscope into the bronchus of the lobe or lung 
involved; (2) by aerosolization through a tracheotomy tube; and (3) by aero- 
solization with a conventional mask used for aerosol treatments. 

Three methods of administering "triton A-20" were: (1) by tent, with 
a nebulized solution flowing into the tent which covered primarily the head 
and neck of the patient; (2) by mask; and (3) by tracheotomy tube. 



12 



Medical News Letter, Vol. Z7, No. 9 



Coughing is accomplished in various ways depending on the type of 
patient. In non-poliomyelitic patients, who cannot or will not cough volun- 
tarily, tracheal catheterization is the best means of producing a cough in 
both tracheotomized and non-tracheotomized patients. In post-poliomyelitic 
patients, the coughing which is extremely important, must be done by arti- 
ficial means. For patients with tracheotomies and in a respirator, a vacuum 
cleaner machine is attached to a porthole in the respirator and the pressure 
decreased to a negative 40 cm. of H2O; this produces a deep inspiration. 
When this pressure is reached, the bedpan port is suddenly opened and a 
satisfactory expulsive force is produced through the open tracheotomy tube. 
A series of 24 coughs is given four times a day. The trachea is aspirated 
as necessary to clear the air passages of secretions. In post-poliomyelitic 
patients without tracheotomy tubes, the vacuum cleaner method cannot be 
used because synchronization of the action of opening the glottis" with the 
sudden expulsive force is difficult or impossible in almost all patients. There- 
fore, "manual coughing" is used. With this method, the attendant compresses 
the thorax synchronous with the expiratory phase of the respirator. Although 
"manual coughing" is not as effective as vacuum coughing, it serves the pur- 
pose in the cases where it is used. These coughing procedures are used 
according to patient type regardless of whether "tryptar" or "triton A-20" 
is used. 

Antibiotics are administered in all cases both by aerosol and paren- 
terally as indicated. Aerosol antibiotics are not used in patients receiving 
"triton A-20" therapy because of the large amounts of solution necessary. All 
patients receive parenteral antibiotics during the course of treatment. Anti- 
biotics are used according to sputum culture and sensitivity tests if feasible. 
(Camarata. S. J. , Jacobs. H. J. , Affeldt, J. E. , The Use of Enzymes and 
Wetting Agents in the Treatment of Pulmonary Atelectasis: Dis Chest 
XXIX: 388-393. April 1956) 

«*#*** 

Effect of Pregnancy on t^e Course of Hear t Disease 

The woman with heart disease who has entered or is planning pregnancy 
will ask a series of questions involving her immediate and remote prognosis. 
One of the questions involves her chance of surviving pregnancy. Many studies 
have been reported evaluating the mortality during pregnancy and the puer- 
perium in women with heart disease. This mortality varies from 3% to less 
than 1% in patients under careful medical management throughout their preg- 
nancies. As pointed out by Hamilton in his recent summary of cardiovascular 
problems in pregnancy, the immediate maternal mortality will be influenced 
by the severity of the heart disease at the time of pregnancy judged by a care- 
ful review of the patient's history with particular regard to the previous 



Medical News Lietter, Vol. Z7, No. 9 



13 



occurrence of episodes of heart failure, the maternal age, the availability 
of good medical and obstetrical advice, and the cooperation of the patient in 
accepting this advice. It will also be affected by the policy of the patient's 
physicians toward the interruption of pregnancy, because if pregnancy is 
interrupted early in all patients with severe heart disease, the immediate 
maternal mortality might decline, possibly at the cost of an increased fetal 
mortality. 

A second question to be expected from the woman with heart disease 
entering pregnancy is what chance she has of producing a living infant. The 
infant mortality when the mother has heart disease has been studied in several 
large clinics. Litzenberg in a recent review of the literature states that the 
mortality of infants born to patients classified fxmctionally in class I and class 
11 by the American Heart Association Classification will be the same as in 
patients with no heart disease, while those born of mothers in class III and 
IV, under the same classification, will have a 30% mortality. 

Thus, these two questions can be answered in fairly definite terms. 
The woman with well compensated heart disease, who is class 1 or class II 
by the functional classification of the American Heart Association, has better 
than a 97% chance of surviving pregnancy and about as good a chance of pro- 
ducing a living baby as the woman without heart disease. 

A third question that the pregnant woman with heart disease logically 
may be expected to ask is in regard to her prognosis for life and health 
once the immediate dangers of pregnancy are past. Few data are available 
to answer this question. For this reason, a follow-up study of those women 
with heart disease who were seen during pregnancy in the Boston Lying-in 
Hospital is being made. This is the first report on that study. 

In 18 months, 91 cardiac patients were delivered and an additional 15 
patients, delivered shortly before July 1950, were seen and evaluated at a 
postpartum visit to the medical clinic. This total of 106 patients included 92 
with rheumatic heart disease, 8 with congenital heart disease, 1 with hyper- 
tensive cardiovascular disease, 1 with combined hypertensive and rheumatic 
heart disease, and 4 with "potential" rheumatic heart disease. 

This group of 106 was selected only insofar as it comprised all the 
patients followed within a specified time interval in a metropolitan obstet- 
rical hospital and referred to the hospital's medical clinic because of heart 
disease. The follow-up period of 3 to 5 years was selected because the changes 
since pregnancy could be evaluated by the same group of physicians that had 
supervised the therapeutic regimen during pregnancy. 

The course of the 106 cardiac patients who were observed during this 
study was surprisingly good in regard to both survival and well-being. There 
were no maternal deaths during pregnancy or in the postpartum period in 
this group of 106 patients. Three to five years after their pregnancies, only 
3 of the 106 patients were dead. Sixty-five patients (61%) were functionally 
unchanged according to the American Heart Association Classification, and 



14 



Medical News Letter, Vol. 27, No. 9 



Z7 patients (26%) showed an improvement in their cardiac functional ability. 
In 5 of these, this improvement could be attributed to valvuloplasty and, in 
another, to resection for coarctation of the aorta. Only 14 patients (12%) 
showed progression of heart disease in terms of functional classification. 

Because of the small number of patients with congenital heart disease 
in this study, no conclusions can be drawn as to the effect of pregnancy on 
congenital heart disease, and the comments apply to the 92 patients with 
rheurnatic heart disease. 

No patient died during pregnancy or the puerperium. Only three have 
died since; 92 patients have shown either no change or an improvement in 
functional classification. 

This re-evaluation indicated that the altered circulatory dynamics of 
pregnancy may temporarily decrease functional capacity. However, no per- 
manent change in degree of heart disease could be directly attributed to the 
pregnancyforwhichthese patients were followed in 1950 and 1 951 . (Miller, M. M. , 
Metcalfe, J. , Effect of Pregnancy on the Course of Heart Disease. Reevalua- 
tion of 106 Cardiac Patients Three to Five Years after Pregnancy: Circulation, 
XIII : 481-488, April 1956) 

sjc !fc s{c sjc s{c sJe 

Palliation of Ovarian Carcinoma with Phosphoramide Drugs 

Ovarian carcinoma ranks fifth as cause of death from cancer in women 
in the United States, although, as pointed out by Ackerman and del Regato, 
only 15% of all pelvic cancers are ovarian in origin. The insidious onset and 
course of this disease frequently delay diagnosis and therapy until distant 
metastases have occurred. Operation on ovarian tumors is often rendered 
difficult by extensive adhesions more or less fixed to the intestine, the blad- 
der, and the pelvic wall. In spite of postoperative treatment with irradiation, 
the majority of these patients rapidly develop abdominal metastases which 
bring about death within a short time. 

Various attempts to correct this serious situation have been made. 
The present article is a preliminary report concerning the observations on 
a group of patients who were treated with two related compounds, N-N'-N" 
tri ethylene thiophosphoramide and N-3 (oxapentam ethylene) N N' diethylene 
phosphoramide. 

Twenty -two patients were included in this study. They ranged in age 
from 31 to 77 years with an average of 54 years. In all cases, diagnosis 
was made by histopathologic examination of material obtained by biopsy or 
resection of tumor. 

Previous therapy included: in the group in which surgery alone was 
performed, biopsy only in 1 case, exploratory operation and biopsy in 4 cases, 
resection of tumor in 7 cases; in the group in which surgery was followed by 



Medical News Letter, Vol. 27, No. 9 



15 



irradiation, exploratory operation in 1 case, resection of tumor in 7 cases; 
and 2 cases in which surgery was supplemented by both irradiation and 
hormone treatment. 

Because pulmonary metastases were demonstrated by x-ray examina- 
tion, 1 patient had biopsy of a neck node only; diagnosis was verified at post- 
mortem examination. InScases, surgery was limited to abdominal exploration 
and biopsy of a tumor nodule. Resection of disease was undertaken in 16 
patients. Eight individuals had 2 or more operations for the disease. Both 
ovaries were involved by cancer in 8 cases. 

Triethylene thiophosphor amide was prepared in a solution containing 10 
mg. of drug per cc. of nonpyrogenic water. Sterilization was achieved by 
filtration and the solution was stored at 4° C. Patients were treated at inter- 
vals of 1 to 3 weeks except in a few instances when the drug was administered 
intravenously every day for 3 to 5 days after which the longer intervals were 
employed. The total amount of triethylene thiophosphoramide given ranged 
from 110 to 780 mg. {average 353 mg. ) in periods of 1 to 22 months {average 
7. 6 months). Due to a temporary shortage of drug and in order not to inter- 
rupt therapy, oxapentam ethylene di ethylene phosphoramide was substituted 
for 1 to 3 doses of 10 to 70 mg. in 8 cases. Oxapentam ethylene diethylene 
phosphoramide was prepared in the same way as triethylene thiophosphor- 
amide with the exception that 20 mg. of cirug were used per cc. of solution. 

The initial dose of drug given by the intravenous route was 10 mg, for 
other routes, doses of 20 to 40 mg. were employed. Subsequent therapy 
depended on the white blood count which was obtained prior to each treatment. 
The dose was reduced when the white blood cells dropped below 5000 per cm. , 
and therapy was usually discontinued temporarily in the presence of a leuco- 
peAia exceeding 3000 per cm. 

Routes of therapy were: intravenous in 16 cases, intrapleural in 3, 
intraperitoneal in 3, intrapericardial in 1, into peripheral tumor masses in 7, 
transvaginal in 16, and transabdominal in 10 cases. 

In all cases, an attempt was made to treat the site of disease which 
presented the greatest threat to the patient's welfare. The transvaginal 
and transabdominal approaches were used when a needle could be inserted 
directly into tumor masses in these areas. Only one site was treated at a time. 

When pleural effusion or ascites occurred, a thoracentesis or para- 
centesis was performed and the drug was injected following the tap. One 
patient received one intrapericaridal injection of triethylene thiophosphor- 
amide following a pericardial tap. Intravenous therapy was reserved usually 
for those occasions when no tumor sites could be reached with a needle. 
Route of therapy varied from time to time depending on the status of the 
patient. 

Although this series of cases is small, all patients included had evi- 
dence of widespread ovarian carcinoma. Death usually occurs within 2 years 
in such^ patients when operation has been incomplete. Ten of the patients 



16 



Medical News Letter, Vol. 27, No. 9 



treated with triethylene thiophosphoramide are alive 5 to Z2 months follow- 
ing the institution of chemotherapy. Two were lost to follow-up. Of the 10 
who have expired, 7 patients had some degree of palliation for periods of 
1 to 7 months. 

Triethylene thiophosphoramide is not difficult to administer even when 
given transvaginally or transabdominally. Treatment is easily given in the 
clinic or the office, and, because there are minimal clinical side effects, 
it is compatible with continuation of normal activities. Reasonable care is 
needed to avoid infection at the site of injection. 

In the presence of extensive disease, treatment must be maintained 
at hematopoietic tolerance. Prophylactic antibiotic medication is not recom- 
mended in order to avoid the hazards of side effects and the development of 
drug resistant infection. However, when infection occurs, it should be 
treated promptly and adequately. Prolonged therapy with the phosphoramides 
appears to be associated with varying degrees of anemia in many cases. It 
is much more apt to occur with oxapentam ethylene diethylene phosphoramide 
injections and may be severe following this drug. Because anemia is fre- 
quently associated with far advamced cancer, and because anemia does not 
always occur with phosphoramide therapy, it is assumed that other factors 
may be involved. Therapy with phosphoramide drugs appears to be palliative 
only and must be continued in order to achieve and maintain control of disease. 

The observations reported appear to warrant further therapeutic trials 
with triethylene thiophosphoramide in ovarian carcinoma. (Bateman, J.C. , 
Winship, T. , Palliation of Ovarian Carcinoma with Phosphoramide Drugs: 
Surg. Gynec. & Obst. , 102: 347-354, March 1956) 

■3^ s{fi sjc ifc sQc 

Methods of Prevention and Control of Dental Caries - 

Approximately 90% of the teeth now lost before middle age could be 
saved in the future adult population of this country by the application of what 
is already known about the control and prevention of dental diseases, A 
major problem is to find the means and the will for applying what is known. 
The public health dentist can play a major role in the solution of that problem. 

Teeth are lost for two principal reasons: (1) destruction of the crowns 
by caries, and (2) destruction of the attaching tissues by inflammation and 
degeneration. Although not all the intricate complications in the etiology of 
caries have been unraveled, sufficient understanding of the basic factors 
has been gained to place preventive treatment on a rational basis; and the 
possibility of controlling the progress of carious destruction through good 
operative dentistry at an early age is well established. 

There are many predisposing conditions that may influence the carious 
process such as age, heredity, emotions, state of health, salivary flow and 



Medical News Letter, Vol. 27, No. 9 



17 



composition, tooth structure, and position, but the actual destructive forces 
are few. Evidence continues to accumulate to support the generally accepted 
theory that bacterial activity is a major factor. The fact that cavities invar- 
iably occur where microorganisms can accumulate and remain relatively 
undisturbed for long periods of time, has provided circumstantial evidence 
that bacteria are associated with the destructive process. Direct evidence 
that bacteria are required for the production of caries is accumulating through 
the germfree animal studies conducted at the University of Notre Dame in 
collaboration with the Zoller Clinic of the University of Chicago. 

The principal agent that destroys the calcified tissues of the teeth is 
probably acid in character. Many investigations have demonstrated the pro- 
duction of cavities in the enamel by weak acids. The only type of food taken 
into the mouth, which can develop an acidity of sufficient strength to dissolve 
enamel, is carbohydrate. The carbohydrates are converted to acid by enzy- 
matic action. The simpler the carbohydrate, the more rapidly is it converted 
to acid. Thus, the simple sugars — glucose, fructose, sucrose — are more 
readily converted than are the polysaccharides (the starches). Many dietary 
studies have shown an association between refined carbohydrate consumption 
and caries activity. It is well known that the amount of caries any popxilation 
experiences is roughly proportional to its sugar consumption. 

When these observations are collated, that is, the association between 
bacteria, carbohydrates, the production of acids from bacterial action on 
carbohydrate and the requirement of acid for tooth destruction, it is obvious 
what the principal factors in tooth destruction are, and what steps can be 
taken to prevent or control this disease. A rationale based on the factors 
outlined for reducing carious activity could include the following: 

1. Restriction of the amount of fermentable carbohydrate in the diet. 

Z. Production of a tooth tissue more resistant to acid and enzymatic 
action, 

3. Removal of fermentable material from the surfaces of the teeth 
before it is converted into acid. 

4. Employment of nontoxic antibacterial agents to eliminate the 
microorganisms associated with the decay process or to interfere 
noticeably with their metabolism. 

5. Placement of inhibitors in the mouth that interfere with or destroy 
enzymes responsible for the conversion of carbohydrate to acid. 

6. Neutralization of acids as rapidly as they are formed on the tooth 
surfaces. 

The most effective means of preventing the initiation of carious lesions 
is a dietary program that sharply reduces the amoiint of sugar consumed. 

Another effective means with sufficient evidence to support the claims 
for it is the use of fluorides either through water fluoridation or topical ap- 
plication of fluoride solutions. Any means for caries control that requires 
conscientious cooperation on the part of the individual, that denies him 



18 



Medical News Letter, Vol. 27, No. 9 



something which he enjoys, or requires him to perform a ritual that is incon- 
venient, cannot be too effective in controlling caries in large numbers of 
people. But an agent that will give partial resistance and that can be pro- 
vided without personal effort on the part of the individual is fluoridation of 
the drinking water. It should be an effective mass means of reducing caries. 

For many years, the toothbrush has been advocated as a weapon against 
caries. Skepticism has developed about its effectiveness because of the in- 
creasing incidence of caries despite the increased sale and use of toothbrushes 
and dentifrices. The reasons for this inconsistency are that the toothbrush 
has not been used at the time of greatest effectiveness nor in the manner that 
cleanses the areas that are vulnerable to decay. Present knowledge indicates 
that the decalcifying phase of the carious process reaches its maximum activi- 
ty within the first 20 to 30 minutes after eating; therefore, the popular habit 
of brushing teeth the first thing in the morning and the last thing at night is 
not rational for caries control. People should be taught to clean the mouth 
soon after eating. 

Nothing new has been revealed in this brief review of caries etiology, 
prevention, and control. Its purpose is to reaffirm faith in what is known, 
and to accelerate more action in its application so that future generations 
will be served more by their own teeth and less by the artificial variety. 
(Kesel, R.G. , Methods of Prevention and Control of Dental Caries : J. Am. 
Dent. A. , 5Z: 455-462. April 1956) 

:{c « ;«c « « 

Comment s on the Revised Dental Standards Relative to Entrance 
to U.S. Navy and Marine Corps Officer Candidate 
Training Programs 

1. During recent weeks, it has become apparent that there is still some lack 
of understanding regarding the recent changes in dental requirements for en- 
trance to the Naval Academy as promulgated by Advance Change 4-5 to the 
Manual of the Medical Department, Art. 15-25. The following comments ar^ 
designed to clarify these revised standards, particularly for dental officers 
conducting screening or preliminary examinations. ^ 

2. The dental requirements for entrance to Navy and Marine Corps Officer 
Candidate Training Programs were changed, not with the intention of admit- 
ting man of lesser caliber to the Academy, but rather to extend the scope 

of opportunity to a greater number of young men considered to be naval 
officer material. In the past, it was felt that perhaps too stringent standards, 
or more precisely, a too stringent interpretation of those standards resulted 
in the failure of too many potentially fine candidates in gaining admittance to 
officer candidate schools. 



Medical News Letter, Vol. 27, No. 9 



19 



3. The new standards and regulations have been published in clear, con- 
cise terminology. The examiner, while keeping the intent of the standards 

in mind, should evaluate the candidate from the standpoint of his potentialities 
as a future naval officer. In fact, in many cases, liberal interpretation of the 
strict letter of the standards may be more than compensated for by the poten- 
tialities of the individual under consideration. It is not intended that these 
requirements be hard and fast rules to keep people out. A liberal interpre- 
tation is desired within the bounds of common sense and professional judg- 
ment to get the right kind of candidate into the officer candidate school. 

4. Some of the requirements are so specific that everyone will place the 
same interpretation upon them, but others are general enough to permit a 
divergence of opinion. Only the nonspecific requirements will be discussed. 

a. L-ack of Satisfactory Incisal Function. A minor failure to actually 
contact the anterior teeth in protrusive relationship is not intended as a 
cause for rejection. Thus, a man with a good set of teeth might be admitted 
as having satisfactory incisal function despite his inability to bring his an- 
terior teeth into exact end to end contact. 

b. Lack of Satisfactory Masticatory Function. Previous to now, 
molar occlusion on both sides of the arch was a necessary qualification for 
admittance. It seems reasonable to assume that satisfactory masticatory 
function would now mean either at least one sound molar in apposition on 
each side of each arch or a partial denture that will furnish bilateral molar 
occlusion. While a person can chew with only one intact side above and below, 
he will undoubtedly soon become a prosthetic problem if he has unopposed 
molars on the other side, hence the desire for molars in apposition on both 
sides. In other words, the setting of a minimum of sixteen teeth as a stan- 
dard is not an indication that men can enter without posterior teeth for mas- 
tication. It has merely made more extensive partial dentures acceptable. 

c. Carious Teeth Except Minor or Questionable Caries. The intent is 
still to insist that applicants have caries corrected prior to admittance to 
officer candidate training programs. Active duty enlisted personnel who 
are candidates should not be disqualified for caries, but appointments 
arranged for remedial treatment. The exception to "minor or questionable 
caries" was made simply to forestall an over-zealous examiner from ex- 
cluding some worthy person because of an unrestored pit or fissure or nicks 
discernable by x-ray on interproximal surfaces. It is very desirable that 
there be no loose interpretation of the term "minor or questionable caries. " 
An example of the need for no loose interpretation of minor caries is the 
following: In 1952, the Bureau made a concession regarding Naval Aviation 
Cadets. It was stated that "free from caries" could be interpreted as 



20 



Medical News Letter, Vol. 27, No. 9 



"moderate or easily correctable caries. " Shortly after that, two NavCads 
arrived at Pensacola with mouths so completely wrecked by caries that 
full mouth extractions had to be carried out. Many others arrived with ram- 
pant caries. The bars had been slightly lowered and the examiners dropped 
them completely. It should be remembered that officer candidates in train- 
ing who have dental caries must sacrifice valuable training or study time to 
receive dental treatment. 

d. Marked Malocclusion. In the past, malocclusion has been the object 
of variable interpretation. It is most significant that the Bureau of Medicine 
and Surgery presently relates malocclusion to facial deformity. This shoTild 
rule out, as causes for rejection, many minor malocclusions such as cross- 
bite, over-jet, over-bite, impingement, et cetera, provided such malrela- 
tionships do not endanger the longevity of the teeth and disfigure the applicant. 

e. Infectious or Chronic Diseases. Slight areas of infection or hyper- 
emia susceptible to treatment or simple correction are not considered dis- 
qualifying. Cases for rejection include those persons with extensive loss 

of gingival or bony tissue. Those persons who may lose their teeth due to 
loss of supporting tissues are those most likely to become dental liabilities. 

5. As one views the new dental standards, it becomes apparent that there 
has been a marked simplification designed to eliminate failure due to tech- 
nicalities. The change permits more applicants to qualify, but does not 
significantly increase the dental workload. Four important changes stand 
out. First, more extensive partial dentures are now acceptable where sound 
natural teeth were previously required. Secondly, malocclusion has present- 
ly been related to facial deformity in an effort to rule out the myriad of mal- 
relationships that previously have caused unnecessary rejections. Thirdly, 
it is significant that the word "vital" has been eliminated as a prerequisite 
for a sound tooth. Thus, a successfully treated non-vital tooth may be 
counted as one of the sixteen natural teeth presently required. Fourth, we 
now have one set of dental requirements for all types of officer candidates. 
(DentDiv, BuMed) 

From the Note Book 

1. Mrs. Ivy B. Priest, Treasurer of the United States, presented to Rear 
Admiral O. B. Morrison, MC USN, Commanding Officer of the U. S, Naval 
Hospital, Portsmouth, Va. , the Minute Man Flag, at a ceremony held at the 
hospital on April 11, 1956. This flag is the U S. Treasury's highest honor 
and award for excellence in participation in the United States Savings Bond 
Program . 



Medical News Letter, Vol. 27, No. 9 



21 



The award, presented for the first time to any naval hospital, is official 
recognition by the Treasury Department and represents high standards of 
excellence for participation in the United States Savings Bond Pay Roll Prog- 
ram for the calendar year 1955. An average enrollment of over 90% for the 
year was maintained by employees of the hospital. (TIO, BuMed) 

2. Rear Admiral I. L. V. Norman, MC USN, served as Alternate for the 
Surgeon General of the Navy on the Board of Governors at the Annual Meeting 
of the American College of Physicians, held in Los Angeles, April 15 - 21, 
1956. (TIO, BuMed) 

3. Rear Admiral W. P. Dana, MC USN, participated as a Bureau of Med- 
icine and Surgery representative and as a member of the Executive Council 
at the Annual Meeting of the Aero Medical Association, held at Chicago, 
April 15 - 19, 1956. (TIO, BuMed) 

4. Captain R.H. Fletcher, MC USN, represented the Bureau of Medicine 
and Surgery at the Health Congress of the Royal Society for the Promotion 
of Health, April 24 27, 1956, at Blackpool, London, England. (TIO, BuMed) 

5. Captains C. L. Riggs and A.J. Cerny, MC USN, are attending as students 
the Twelfth Interagency Institute for Federal Hospital Administrators, held 

at the Walter Reed Army Medical Center, Washington, April 23 - May 11, 
1956. (TIO, BuMed) 

6. Letters were recently sent by the Dental Division, Bureau of Medicine 
and Surgery, congratulating Reserve Dental officers upon selection to the 
grade of Captain or Commander. 

Promotion Is perhaps the paramount motivating factor in the minds of 
active Reservists in their Reserve participation. Many letters have been 
received in the Bureau from these recent selectees in answer to those of the 
Division, Practically all expressed their appreciation for the selection and 
their intention of remaining active in the Reserve Program. These men, by 
their example, are the leaders in the Reserve Program; they have been active 
since 1945 and have provided the leadership necessary to maintain a strong 
Dental Reserve. (TIO, BuMed) 

7. The U.S. Naval Hospital, Philadelphia, Pa. , was co-host with the Phila- 
delphia County Dental Society for the Seventh Annual Combined Meeting on 

4 April 1956. Over 350 civilian dentists and physicians from a five -state 
area heard Dr. M.S. Aisenberg, Dean, School of Dentistry, University of 
Maryland, discuss: The Diagnosis of Oral Malignancies. (USNH, Philadelphia, 
Pa. ) 



22 



Medical News Letter, Vol. 27, No. 9 



8. Captain P.B. Phillips, MC USN, Head of the Department of Neuropsy- 
chiatry at the Naval School of Aviation Medicine, Pensacola, Fla. , addressed 
the annual meeting of the Gulf Coast Industrial Council in Biloxi, Miss. , 
April 6, on Dealing with the Personality Extremes . ( SchAvMed, NAS. 
Pensac ola) 

9- An exhibit entitled Enrich Your Professional Career , Nurse Corps, USN 
was shown at the Washington State Nurses Convention in Spokane, Wash. , 
April 18 - 20, 1956. The important phases of service in the Nurse Corps 
were illustrated in this exhibit. (TIO, BuMed) 

10. Clinical histories, operative findings, and end-results of 16 patients who 
have undergone surgical removal of traumatic intracerebral hematomas are 
reviewed in Ann. Surg., March 1956; R. L,. McLaurin, M. D., B. H. McBride, 
M. D. 

11. A detailed statistical study of the prevalence of periodontal disease, based 
on dental examination of nearly 13, 000 employees of the Metropolitan Life 
Insurance Company, has been made. The study includes the total prevalence 
of the condition, of the extractions for it, and facts on the proportion of the 
individual teeth affected or extracted. (J. A. D. A. , April 1956; W.A. Bossert, 
D.D. S., H. H. Marks, A. B. ) 

12 The effects of arctic climate and different shelter temperatures on the 
ECG were investigated in 7 normal young men performing standard work out- 
doors in arctic and temperate climates. (Am. Heart J. , March 1956; Captain 
L. A. Kuhn, MC USA) 

13. Marjolin's ulcer may be briefly defined as a cancer arising in a burn 
scar. Three cases of Margolin's ulcer are presented in Surgery, April 1956; 
R.J. Schlosser, M. D. , E.A. Kanar, M.D. , H.N. Harkins, M.D. 

14. The management of pulmonary embolism and pulmonary infarction is 
discussed in PostGraduate Medicine: March 1956 ; L. J, Boyd, M. D. , E, J. 
Nightingale, M.D. 

15. The value of a yearly physical survey in the adult female is discussed 
in J.A M.A., 14 April 1956; R.N. Rutherford, M.D., A. L. Banks, M.D. 

16. Four similar cases of fatal fat embolism are presented with emphasis 
on the clinical and pathological findings. The diagnosis of fat embolism is 
often missed because of the uncertain nature of the disease in its milder forms 
and because of a lack of awareness of the attending physician. { Arch, Surg. , 
April 1956; Major T. G. Nelson MC USA, Colonel W. F. Bowers, MC USA) 



Medical News Letter, Vol. 27, No. 9 23 



Recent Research Projects * 
Naval Medical Research Institute, NNMC, Bethesda, Md . 

1. The Acetylcholinesterase Surface. V. Some New Competitive Inhibitors 
of Moderate Strength. NM 000 018. 12. 03, 9 November 1955. 

2. The Interaction Between Acetylcholine and Atropine on the Isolated Frog 
Heart. NM 000 018. 12. 01, 14 November 1955. 

3. Metabolic Studies of Intact Perfused Calf Adrenals Using Tetrazolium. 
NM 006 012. 04. 88, 15 November 1955. 

4. Emergency Laboratory Organization for the Care of Large Numbers of 
Human Beings Accidentally Exposed to Ionizing Radiation. NM 006 012. 04. 91, 
18 November 1955. 

5. The Effect of Extreme Cold Exposure on Adrenocortical Function in the 
Unanesthetized Dog. NM 007 081.22.05, 1 December 1955. 

6. Corresponding States in Multilayer Step Adsorption. NM 000 018. 06.44, 
2 December 1955. 

7. Radiation Dosimetry in Biological Research. NM 006 012. 04. 92, 9 Dec- 
ember 1955. 

8. An Analysis of the Effects of Total Body X-Irradiation on the Body Weight 
of White Mice. II. Body Weight Changes of Male Mice as a Biological Dosim- 
eter. NM 006 012. 04. 68, 9 December 1955. 

9. Approximate Calculation of the Electrostatic Free Energy of Nucleic 
Acids and Other Cylindrical Macromolecules. NM 000 018. 06. 42, 9 Decem- 
ber 1955. 

10. A New Technique for the Study of Drug Actions on Bronchial Resistance in 
the Isolated Lung. NM 000 018. 12.05, 12 December 1955. 

11. The Effects of Aging and the Modifications of These Effects, on the Immun- 
ity of Mosquitoes to Malarial Infection. NM 005 048. 06. 08, 12 December 1955. 

12. Conversion of Steriods to Aldosterone -like Material. NM 006 012. 04. 90, 
13 December 1955. 

13. Secondary Kidney Homotransplantation. NM 007 081. 21. 03, 13 December 
1955. 

14. A Technique to Minimize Color Changes in Ocular Prostheses. Memo. 
Report 55-7. NM 000 018.07, 19 December 1955. 

15. The Freezing and Thawing of Whole Blood. NM 000 018.01. 10, 19 Dec- 
ember 1955. 

16. Selection and Preliminary Adaptation of Rats for Work in the NMRI 
Multiple Choice Box. NM 000 019.01.03, 20 December 1955. 

17. A Thirty-Day Cariogenic Diet for Osborne-Mendel Rats. NM 008 012. 
01. 14, 22 December 1955. 

18. Summaries of Research. 1 July - 31 December 1955. 

19. Regulation of the Secretion of Aldosterone -like Material. NM 006 012. 
04.89, 18 January 1956. 



24 Medical Neiws Letter. Vol. 27. No. 9 

Naval Medical Research Laboratory, Submarine Base, New London , Conn. 

1. Exposure Test of Fluorescent Paints to Sun and Salt Water. Memo. 
Report 56-1. NM 002 014. 09. 05, 3 January 1956. 

2. Evaluation of Three Waterless Handcleaners. Memo. Report 56-2. 
NM 002 015. 14. 03, 19 January 1956. 

3. Field Evaluation of Modified Submarine Rescue and Escape Suits. Memo 
Report 56-3. NM 002 013. 01.03, 9 February 1956. 

4. Photometric Survey of Lighting Installation on the Submersible Craft 
X-1 (SSX-1). Memo. Report 56-5. NM 002 014.08. 12, 29 February 1956. 

Naval School of Aviation Medicine, NAS, Pensacola, Fla . 

1. The Acetylcholinesterase Surface. VI. Further Studies with Cyclic 
Isomers as Inhibitors and Substrates, NM 000 018, 12.04, 6 December 19 

2. A Study of Intelligibility and Selective Filtering with a Unidirectional 
Communications Net. Report No. 62. NM OOi 104 500, 15 December 1955. 

♦(Continued from Volume 27, No. 8) 

Postgraduate Course Offered to Navy Medical Officers 

Applications are desired from Regular Navy medical officers and 
Reserve officers who have recently reported to active duty for attendance at 
a course of instruction in Preventive Medicine, to be conducted at the Naval 
Medical School, National Naval Medical Center, Bethesda, Md. , commencing 
10 September 1956. 

Purpose . This course is offered in order to better prepare medical 
officers for their service in the Navy. It will also serve to prepare eligible 
flight surgeons of the Navy and Air Force for examination by the American 
Board. The course is designed to assure knowledge of current principles 
and practices in preventive medicine at administrative and non-laboratory 
operational levels. Of primary concern are requirements of the military 
forces, their industrial activities and their essential relationships with civil 
commimities , 

Length of Course . The course covers 18 weeks of lectures, laborator 
and field observations, seminars and individual studies. Approximately 520 
class hours are scheduled with time held in reserve for study and augmenta- 
tion of individual subjects as found necessary. 

Instruction Personnel. Highly qualified staff personnel, augmented by 
visiting lecturers from academic institutions, the Public Health Service, 
and the other Armed Services, 

The course content includes the following: 

1. Introduction to Biostatistic s 

2. Epidemiology 



Medical News Letter, Vol. 27, No. 9 



25 



3. Environmental Preventive Medicine 

4. Health Practice - general 

5. Health Practice - specialized fields 

Requests from interested and eligible personnel should be submitted 
via official channels to the Chief of the Bureau of Medicine and Surgery. 
Attendance will be on a temporary duty under instruction basis with travel 
and per diem provided. Enrollment is limited to 12 officers of the Navy plus 
12 officers of the U.S. Air Force. Deadline for receipt of applications is 
1 August 1956, Reliefs cannot be provided for those approved for attendance. 
Minimum security clearance classification of Secret is required for attendance. 
(ProfDiv, BuMed) 

« 3(: li; 9(c 

BUMED INSTRUCTION 6200. 2A 20 March 1956 

From: Chief, Bureau of Medicine and Surgery 

To: Stations Having Medical /Dental Personnel Regularly Assigned 
Subj; Liaison with Public Health Service 

End: (1) Joint Army Navy -Air Force directive re subject 

This instruction, through enclosure (1), incorporates into the Navy Directives 
System a revised joint Army-Navy- Air Force directive on liaison with the 
Public Health Service. BuMed Instruction 6200.2 is canceled. 



BUMED NOTICE 6230 3 April 1956 

From: Chief, Bureau of Medicine and Surgery 
To: All Ships and Stations 

Subj: Poliomyelitis vaccine 

Ref: (a) BuMedlnst 6230.8 of 16 Sep 1955, Subj: Poliomyelitis; 
immunization of dependents against 

(b) BuMedlnst 6230.8 Sup-1 of 16 Dec 1955, Subj: Poliomyelitis 
vaccine, Salk; distribution and use of in the continental United 
States 

(c) U. S. Navy Medical News Letter, Vol. 27, No. 3 pp. 35 - 37, 
3 Feb 1956 

(d) U.S. Navy Medical News Letter, Vol. 27, No, 5, pp. 32 - 34, 
2 Mar 1956 



26 



Medical News Letter, Vol. 27, No. 9 



This notice promulgates information on current status of procurement and 
distribution of poliomyelitis vaccine for immunization of dependents of Navy 
and Marine Corps personnel. 

:tc :{c :tc 4: # 3(: 

BUMED NOTICE 5213 6 April 1956 



From: Chief, Bureau of Medicine and Surgery 

To: Activities Under Management Control of BuMed 

Subj: Recurring reports; review of 

Ref: (a) BuMedlnst 5210.4 of 9 Sep 1955 (Notal), Subj: Hospital forms, 
reports, and records disposal programs 

End: (1) Guide for Conducting Review of Reports 

(2) Flyer "Improve Your Reports" 

(3) Format for submitting recurring reports recommendations 
{4) Format for indicating results of review 

This notice directs an intensive review of all recurring reports and sets 
forth procedures for carrying out this review. 

*.***** 

BUMED NOTICE 1080 6 April 1956 

From: Chief, Bureau of Medicine and Surgery 

To: Ships and Stations Having Medical /Dental Personnel Regularly 
Assigned 

Subj: NavMed-HC-3 Card; modification in submission of 
Ref: (a) Subarticle 23-6(3)(d)( 10), ManMed 

This notice advises addressees of modification in the submission of the Nav- 
Med-HC-3 card. 

3^ S}c 9^ 3^ sfc sjc 

BUMED INSTRUCTION 6510. 5A 9 April 1956 

From: Chief, Bureau of Medicine and Surgery 

To: Ships and Stations Having Medical/Dental Personnel Regularly As signed 



Medical News Letter, Vol, 27, No. 9 



27 



Subj: Histopathology centers; designation of 

Ref: (a) BuMedlnst 6510. 2A, Subj: Armed Forces Institute of Pathology 
and Histopathology Centers; central facilities provided for 
Department of Defense by 

This instruction provides a revised list of activities designated or redesig- 
nated as histopathology centers by the Director, Armed Forces Institute 
of Pathology in conformance with Section II, paragraph 4 of reference (a). 
BuMed Instruction 6510. 5 is canceled. 

BUMED INSTRUCTION 6320. 9C 17 April 1956 

From: Chief, Bureau of Medicine and Surgery 

To: All Ships and Stations Having Medical Personnel Regularly Assigned 

Subj: Outpatient Report, DD Form 444 (Report Symbol Med-6320-5) 

This instruction- revises instructions for the preparation and submission of 
subject report in its new format and content prescribed by the Department 
of Defense. BuMed Instruction 6320. 9B is canceled. 

BUMED NOTICE 6320 19 April 1956 

From: Chief, Bureau of Medicine and Surgery 

To: Naval Hospitals and Activities Having Station Hospitals or Dispen- 
saries with Authorized Beds. 

Subj; CH-1 to BuMed Instruction 6320. 19A, Subj: Report of Treatment 
Furnished Pay Patients, Hospitalization Furnished (Part A), DD 
Form 7; reporting requirement for 

End: (1) Revised enclosure (1) for subject Instruction 

This notice reflects current billing procedures of the Bureau which require 
separate DD Form 7 reporting for additional components of supernumerary 
pay patients. 



****** 



28 



Medical News Letter, Vol. 27, No. 9 



DE1\TAI 



Selection for Residency or Advanced Training - 
Fiscal Year 1957 

The Dental Officer Training Committee, Dental Division, Bureau of 
Medicine and Surgery, on 2 March 1956, selected the following Naval Dental 
officers for residency or advanced training during the fiscal year 1957: 

Residency Training in Oral Surg ery 

{First Year Lfevel) 

Captain Raymond J. Graves DC USN, Naval Hospital, Chelsea, Mass. 
CDR John L. K eener DC USN, Naval Hospital, Portsmouth, Va. 
LCDR William J. Kennedy DC USN, Naval Hospital, Philadelphia, Pa. 
LCDR Robert S. Neskow DC USN, Naval Hospital, St. Albans, N. Y. 

(Second Year Level) 

Capt. Paul O. Lang DC USN, Naval Dental School, Bethesda, Md. 
CDR David V. Castner DC USN, Naval Hospital, San Diego, Calif. 
CDR Jackson F McKinney DC USN, Naval Hospital, Oakland, Calif. 
LCDR Guy R. Courage DC USN, Naval Hospital, Great Lakes, Ul. 

Advanced Prosthodontic Training 

CDR Elwood R. Bernhausan DC USN, Naval Dental Clinic, Norfolk, Va. 
CDR Don L. Maxfield DC USN, Naval Station, T.I. , San Francisco, 
Calif. 

CDR Christopher E. Thomlinson DC USN, Naval Dental School, 
Bethesda, Md. 

LCDR Frank J. Kratochvil DC USN, Naval Dental School, Bethesda, Md. 
LCDR Ben C. Sharp DC USN, Naval Station, T.I. , San Francisco, Calif. 
LT Fred N. Amman DC USN, Naval Dental Clinic, Norfolk, Va. 
LT Irving J. Weber, Jr., DC USN, Naval Dental Clinic, Brooklyn, N. Y. 
LT Andrew (n) Wyda DC USN, Naval Dental Clinic, Brooklyn, N. Y. 




SECTIOIV 



Medical News Letter, Vol. 27, No. 9 



Advanced PeTiodontic Training 
(First Year Level) 

LCDR Peter F. Fedi DC USN, Naval Station, T.I. , San Francisco, 

Calif. 
(Second Year Level) 

CDR Dwight W. Newman DC USN, Naval Dental School, Bethesda, Md. 

Remnants and Records 

The value of accurate dental records as a means of identification was 
highlighted again recently in the Bureau of Medicine and Surgery. The remains 
of a mandible and fragments of a maxilla with five teeth, received from an 
overseas base, were identified beyond question as belonging to one of six 
individuals whose names were listed as plane crash victims. Accurate recor- 
ding of restorations in 1948 by Captain Leo E. Brenning, DC USN, on a Nav- 
Med H-4 and a remark stating "diastema #7, 8, 9, 10, 11, 26, 27 areas, " 
made in 1953 by Captain Frank D. Dobyns, DC USN, on a SF 603 , were the 
contributing factors which made the identification possible. Accurate and 
detailed dental records such as these are a gratification to those who are 
called upon to identify an unknown when other evidence is either missing or 
meager. 

Captain Leo E. Brenning, DC USN, is presently on duty at the U.S. 
Naval Air Station, Norfolk, Va. , and Captain Dobyns is presently assigned to 
USS Tutuila (ARG-4). 

iff iff ii: >lf ij: if/: 

Dental Activities Within the Naval Service 

According to a recent study in the Dental Division, there are now 434 
Naval Dental activities. One hundred and eighty-seven of these activities 
are located in naval districts; 247 are in Atlantic and Pacific Fleet Commands. 
In addition to these, 10 mobile dental units supply dental care to isolated naval 
activities. 

sic 3|: :^ ^ 

Members of American Society of Oral Surgeons 

The files of the Dental Division, Bureau of Medicine and Surgery, indicate 
that the following Naval Dental officers are members of the American Society 
of Oral Surgeons: 



30 



Medical News Letter, Vol. 27, No. 9 



Rear Admiral Ralph W. Taylor 
Captain Gerald H. Bonnette 
Captain Donald E. Cooksey 
Captain Walter W. Crowe 
Captain Roger G. Gerry 
Captain Harold G, Green 
Captain Raymond F. Huebsch 



Captain Harvey S. Johnson 
Captain William B. Johnson 
Captain Charles J. Schorck 
Captain Arthur S. Turville 
Captain Wilbur N. Van Zile 



Commander Edward A. Garguilo 
Commander Jerome C. Stoopack 



sjc 2^ 3^ 3^ 3^ 



V 



Dental Service at USNH, Memphis 
Approved by ADA 



Dr. Gerald B. Casey, Secretary, Council on Hospital Dental Service, 
American Dental Association, has informed the Commanding Officer, U.S. 
Naval Hospital, Memphis, Tenn. , that its Dental Service has been approved 
by the Council. Captain Cline O. Williams, DC USN, is the Chief of Dental 
Service. 



The catalog number of the Naval Dental Corps film, "Aseptic Pro- 
cedures in Oral Surgery, " listed on page 28 of the 2 March issue of the 
Medical News Letter, is erroneous. The correct number is NM-7930. 



Attention is called to the article entitled, "Comments on the Revised 
Dental Standards Relative to Entrance to U.S. Navy and Marine Corps Officer 
Candidate Training Programs, " appearing on page 18 of this issue of the 
News Letter. 



The printing of this publication has been approved by the Director of 
the Bureau of the Budget, 16 May 1955. 



4: 4c 4: if + 



Correction of Catalog Number - 
Naval Dental Film 



****** 



Revised Dental Standards 



ijc 4c « * * * 



]|c 9(c sjc * * 4c 



Medical News Letter, Vol. 27, No. 9 



31 



JWEDICM RESERVE SECTIO]\ 



Meeting of Military Medicine Section - 
American Medical Association 

. The Military Medicine Section of the American Medical Association's 
Annual Scientific Prograin will meet, June 12 - 14, 1956, at the Cinema 
Theater Auditorium, 151 East Chicago Avenue, Chicago, 111. 

In announcing the meeting. Captain Cecil L. Andrews, MC USN, Sec- 
retary of the Military Medicine Section, stated that this year's important 
and extremely valuable program will include papers by leading military 
and civilian physicians and scientists from all parts of the nation. Captain 
Andrews is Director of the Professional Division in the Navy's Bureau of 
Medicine and Surgery. 

Reserve Medical officers (Inactive) of the Navy, Army, and Air Force, 
who register their presence, will receive retirement point credits for atten- 
dance at the Military Medicine Section of the meeting. Eligible medical 
officers are urged to take advantage of this opportunity. One point will be 
awarded for each day attended. 

Rear Admiral H. Lamont Pugh, MC USN, Chairman of the Military 
Medicine Section, will present the opening address at 9:00 a.m. , Tuesday, 
June 12, 1956. 

^ :4c :ie ^ 4: 

Chec k Your Promotion Points - 
Fiscal Year Deadline is Approaching 



If you are a Reserve officer in a promotion zone for fiscal year 1957, 
bear in mind that you mut have earned, by 1 July 1956, one -half of the 
number of promotion points required for professional qualification after 
selection. 

Officers who do not meet this requirement will not be considered for 
selection. In other words, if you need 96 points to qualify professionally 
for promotion, you must have earned at least 48 of these points before 
1 July. This requirement is in addition to that of earning at least 12 retire- 
ment points during fiscal year 1956. 

Further information on the promotion of Naval Reserve officers may 
be found in the September 1955 issue of The Naval Reservist . 




32 



Medical News Letter, Vol. 27, No. 9 



The number of promotion points required by all officers in fiscal 
year 1957 promotion zones are shown below: 

Present Rank - Points Required to be Points Required to Qualify 

Date of* Considered Professionally 



1 July 1950 or earlier 


72 


144 


2 July 1950 to 1 July 1951 


72 


144 


2 July 1951 to 1 July 1952' 


60 


120 


2 July 1952 to 1 July 1953 


48 


96 


2 July 1953 to 1 July 1954 


36 


72 


2 July 1954 to 1 July 1955 


24 


48 


2 July 1955 to 1 July 1956 


12 


24 


2 July 1956 to 1 July 1957 









* Or date of acceptance of original appointment in the Naval Reserve if after 
date of present rank. (The Naval Reservist, March 1956) 




feb PREVEIMTIVE MEDICIIVE SECTION 



Poliomyelitis Vaccine 



{This is the fourth in a series of articles on the current status of the distribu- 
tion of poliomyelitis vaccine for use in dependents of Navy and Marine Corps 
personnel. ) 

Questions reaching the Bureau of Medicine and Surgery in recent weeks 
indicate that many medical officers are having problems in relation to the 
dosage schedule for poliomyelitis vaccine. Some of the questions and answers 
follow: 

Q. If the second dose cannot be given within 4 weeks following the first 
dose, does the course have to be started over? 

A. No. There is no limit to the interval that can elapse between first 
and second doses. Two to four weeks is the minimum interval rather than 



Medical News Letter, Vol. 27, No. 9 



33 



the maximum and the closer the second dose to the "poliomyelitis season" 
the better. If 7 or more months have elapsed, the second dose will probably 
provide the "booster" response now sought with a third dose. 

Q. Is not the second dose necessary to provide protection against polio? 

A. No. The majority of the antibodies that are found after two doses 
have been given within a 4-week interval, were stimulated by the first dose. 
The second dose does add to the antibody response and presumably increases 
the protection. As noted in the Preventive Medicine Section of the 9 December 
1955 issue of the Medical News Letter, the Poliomyelitis Surveillance Unit 
has reported that one dose afforded significant protection during the summer 
of 1955. 

Q. Will children vaccinated during the summer or fall of 1955 need 
the third dose this spring or summer to be protected? 

A. This cannot be answered unequivocally. There is no question that 
another injection given 7 months or more after the first dose elicits the 

"booster" antibody response which is much greater than that following the 
first two injections, and that it is desirable for maximum protection. It is 
thought, however, that children vaccinated in 1955 will have some protection 
left, either from residual antibody levels or from ability to respond to infec- 
tion anamnestically. Because of the shortage of vaccine, third doses or 

"boosters" are not planned until a majority of other children have had the 
first two doses. 

Since the last article on this subject appeared in the Preventive Med- 
icine Section of the April 6 issue of the Medical News Letter, additional 
allocations of poliomyelitis vaccine have been received and distributed to 
the field. The total now distributed vifithin the continental United States is 
113, 583 cubic centimeters. If used only to give a first dose to eligible depen- 
dents, as recommended, this amount would meet first dose requirements for 
about 60% of dependents according to the figures submitted in January. As of 
this writing, the new requirements, which were to have been submitted on 
30 March, have not been received from all naval districts, but, to the extent 
that they have been received, they do not appear to have changed to any sig- 
nificant degree from the earlier submitted requirements. 

The Weekly Report of Morbidity and Mortality from the National Office 
of Vital Statistics, Department of Health, Education, and Welfare for April 6, 
1956, summarizes the incidence of poliomyelitis for the first 3 months of 
1956. The total incidence for the first quarter of 1956 is about the same as 
for the corresponding period of 1955, although the percentage reported as 
having paralytic poliomyelitis is greater. A greater incidence in 1956 is 
reported from the following States and Territories: Maine, Massachusetts, 
Wiscbnsin, Missouri, Louisiana, Texas, Arizona, California, and Hawaii. 



34 



Medical News Letter, Vol. 27, No. 9 



This distribution does not lend any support to arguments that naval activities 
in some continental areas should receive priority in distribution of vaccine 
because of greater risk. Also, the Public Health Service has recently rejec- 
ted suggestions that priorities be given to States in the southern United States 
because of the earlier onset of epidemics and greater incidence than in north- 
ern States. In the past, it has proven virtually impossible to predict areas 
that may have severe epidemics during any one summer; an area that is hard 
hit one summer is often spared the next year. In the distribution of the Navy's 
share of the vaccine, every effort is being made to provide enough vaccine for 
the first dose to eligible dependents in all areas prior to the summer months 
in the belief that the first dose will provide a significant degree of protection. 
Then, as quickly as supplies will permit, vaccine for second doses will be 
distributed. Requests for special allocations are being considered only when 
made from an area in which epidemic conditions already have occurred. 

^ ^ !^ 

Swimming Pool Sanitation 

The responsibility for vigilance over the aspects of the operation of 
swimming pools and over the maintenance and laboratory practices, which 
pertain to health protection, is delegated to the Medical Department. To 
carry out this responsibility, medical officers concerned should familiarize 
themselves with current directives pertaining to swimming pool sanitation. 

In many areas, outdoor swimming pools will be opened in the near 
future, and it is obvious that in combating disease transmission pools must 
be operated in a sanitary manner. To insure this, the following precautions 
are of essential importance; 

1. Prior to entering the pool, all bathers should take a cleansing shower 
in the nude, using soap liberally and paying particular attention to the 
cleansing of body orifices. 

2. Individuals with evidence of infectious or communicable diseases 
should be forbidden the use of the pool. 

3. Chlorine test of water in the pool should be made at least twice daily. 
During periods of heavy bathing load the chlorine tests should be 
made at least once an hour. The results of the tests should be recor- 
ded in the log. The log should indicate whether the residual of chlor- 
ine is free or available. 

4. Contaminating the pool, runways, and dressing rooms by spitting, or 
in any other way, should be strictly prohibited. 

5. Consumption of food in the pool area proper should be forbidden. 

6. Regardless of the type or capacity of a pool, the water should always 
be clear — free from scum and slime mold. 



Medical News Letter, Vol. 27, No. 9 



35 



7. Domesticated pets should not be allowed in the pool area. 

8. All safety devices should be maintained in good working condition 
and stored in their proper places. 

9. Pool regulations should be posted in conspicuous places and all 
bathers should be encouraged to read them. 

Swimming pools may be considered a combination of public toilet, 
dressing room, and bathroom. Many individuals using swimming pools are 
careless and irresponsible. Therefore, it is the duty of every operator to 
ascertain that facilities are maintained in good sanitary condition. When 
the health of personnel is involved, only the highest standards of sanitation 
are to be tolerated. 

Distribution of a chapter of the Manual of Naval Preventive Medicine 
concerning swimming pools and bathing places is in prospect for the near 
future. Meanwhile, the Manual of Naval Hygiene and Sanitation (NavMed 
P-126) and Special Services (Welfare and Recreation) Facilities (NavDocks 
TP-Pw-13) are the authorized references for swimming pool sanitation. 

Report on the Sanitation Aspects of the Operation - 
"Passage to Freedom" 



Contained herein are excerpts from a report by a member of the 
Medical Unit designated as Task Unit Number 90. 8. 6 of the sanitation aspects 
of the operation, "Passage to Freedom" — the evacuation of Vietnamese refugees 
from the Haiphong area of French Indochina. Commander (now Captain) Julius 
M. Amberson, MC USN, established the Unit as officer -in-charge and was 
later relieved by Commander (now Captain) Sidney A. Britten, MC USN. 

The officers of CTU 90. 8. 6 moved into a , hotel in Haiphong from the 
USS Estes on August 25, 1954. The enlisted men of the Unit were transferred ' 
to the USS Knudson for billeting on the same date. As the materials ordered 
by dispatch by the Unit had not arrived, the first 2 weeks were devoted to the 
development of liaison with the French and Viet-Nam authorities and to the 
study of the various phases of the refugee problem — from the arrival of the 
refugees in the Haiphong area through their embarkation aboard French LSM's 
to their ultimate transfer aboard the vessels of the U.S Navy in BaiD'Alohg. 

Up to this time, no organized camps had been established, although a 
tent camp (Camp Shell) was being constructed to house 2000 refugees, and 
another {Camp de la Pagode) was being planned to house 7000. Neither site 
met the usual campsite requirements because of the high water level which 
frequently caused the inundation of large areas of the camps. No other ground 
was available, however, because all desirable space had been preempted for 
military camps. Latrines with slabs of the ASSAM type were constructed, 



I 



36 



Medical News Letter, Vol. 27, No. 9 



but, because of the high ground -water level, the latrine pits were usually 
about two. thirds full of water. Because of the inconvenient location of the 
latrines and a lack of sanitation discipline, the indiscriminate deposition of 
feces and other wastes continued to be the rule, rather than the exception. 
This posed quite a problem for CTU 90. 8. 6 because the Unit served merely 
in an advisory capacity and had no jurisdiction in the camps. At length, after 
considerable consultation with both the French and Viet-Nam authorities, CTU 
90. 8. 6 prevailed upon them to employ individuals in the camps whose sole 
function would be to maintain satisfactory sanitation. When Camp de la Pagode 
was completed and opened, a Viet-Nam police group was installed. The con- 
certed effort of the police group and the Senegalese military guards, in which 
both educational and police tactics were employed, brought about a semblance 
of sanitation. However, it fell considerably short of Navy sanitation standards. 

The sanitation was less than basic in the other refugee areas which util- 
ized church, school, and park properties in Haiphong. The latrines available 
were too few and the refugees seemed to prefer the slabs of the latrines, the 
walks, and, occasionally, the grass. School buildings housing refugees were 
excessively crowded with whole families living in the corridors, under and 
on top of piles of school desks, on the stair landings, and in other available 

s spots. The preparation of meals over wood fires, built either on the tile of 
the passageways or in the yards, presented a tremendous fire hazard because 
the buildings were of wood, or wood and stucco construction. 

Before the construction of the two camps, a "shanty town" existed about 
15 kilometers to the northwest on the road to Hanoi. At this point, the refu- 
gees were deposited by trains. No provisions had been made for their recep- 
tion. The people improvised shelters from any material available — rice mats, 
cardboard, plastic raincoats, et cetera. The conditions in this area were 
beyond description. Potable water and food were nonexistent and no toilet 
facilities were available. Under the torrid sun, heavy odors pervaded the 
still air when the Unit visited the area, and tremendous numbers of flies 
swarmed over the refugees and their possessions. The children were emac- 
iated, hot, and dirty. The interpreter. Lieutenant D, R. Davis, MC USN, 
was informed by a French -Canadian priest that he had brought this group of 
2500 and also two other groups on earlier occasions into Haiphong to escape 
the Viet-Minh, The group had had neither food nor water for 15 hours. Before 
the Unit left this site, a convoy of trucks arrived and the refugees were moved 

\ to more permanent campsites. On the recommendation of CTU 90. 8. 6, the 
authorities discontinued this site and had it isolated with barbed wire instal- 
lations. 

The first of the Unit's equipment arrived after 2 weeks and two power 
dusting machines were set up immediately for delousing with DDT powder. 
By utilizing its four enlisted men and others from the surgical teams, the 
Unit worked in one or two lines as the need arose. At this time, the Navy 
was evacuating daily from 2000 to 4000 refugees each of whom with his meager 



Medical News Letter, Vol. 27, No. 9 



37 



belongings received a thorough dusting. The Unit's operation replaced the 
laborious process of dusting with hand dusters formerly used regularly 
aboard ship. The author supervised and assisted in the dusting, and Doctors 
Amberson and Davis closely scrutinized each refugee, on the alert for signs 
of contagious diseases which might imperil the health of the crews of naval 
vessels. 

The Unit encountered a Viet-Nam interpreter who had made the trip 
to Saigon with one load of refugees. His story of the fine treatment accorded 
the refugees aboard the naval vessel by the officers and men was so enthrall- 
ing that CTU 90. 8. 6 contacted officials of the United States Information Service 
and suggested that this story be given widespread publicity to counter the heavy 
propaganda of the Viet-Minh. The story was published in the Viet-Nam papers, 
and the U. S. Information Service printed it inleaflets and posters and dispersed 
them to the back areas. The leaflets were used also to wrap the small loaf 
of hard bread with a filling of meat and cheese that was given to each refugee 
at embarkation by the Viet-Nam social agencies. 

After the first day's dusting operation, the Unit encountered little resis- 
tance to the dusting process due to the fact that the camp authorities had 
informed the people, at the Unit's request, as to what they could expect and 
why. The embarkation schedule frequently called for embarkation of military 
personnel and their dependents at other points. To these points, a machine 
and its crew of corpsmen were dispatched for the dusting operation; occasion- 
ally, dusting operations proceeded at three widely separated points simultan- 
eously. Eventually, withi the departure of the surgical teams, it was necessary 
to request enlisted men of the vessels in port for utilization in the dusting 
under the supervision of a corpsman. With a little careful supervision, these 
men fitted very well into the operation. 

Approximately 3 weeks after the arrival of the Unit in the Haiphong area, 
field water purification units arrived, A water purification plant was set up 
in the newly established Camp de la Pagode in a relatively clean pond. How- 
ever, the refugees' complaints about the taste of the water led the camp 
director to move the plaint to an excessively muddy pond used for washing 
clothes, food, and the body. Guards were posted to prevent contamination 
as much as possible, but the water drained off the rice paddies which the 
people used as latrines. Nevertheless, the refugees all agreed that the water 
from the second pond tasted better. The production by CTU 90. 8. 6 of about 
3000 gallons of potable water per day was obviously appreciated by the refugees. 

Frequently, during periods of heavy rainfalls and high tides, the water 
point and about two -thirds of the camp became inimdated with as much as 
12 inches of water. This problem interfered considerably with the operation. 
With the aid of some silver nitrate, the Unit determined that with each inunda- 
tion the high tides brought in salt water which neutralized the treatment chem- 
icals, thus rendering ineffectual the Unit's efforts to produce a clean potable 
water. Inasmuch as considerable effort and thought had been expended in the 



38 



Medical News Letter, Vol. 27, No. 9 



production of potable water, it was somewhat of a relief to find that the 
sudden foul-up was due to no error in the operation. 

The French had placed several hand-operated, so-called purification 
units in the camps. These units, when operated properly, were capable of 
turning out a fair sample of water. However, they were operated in such a 
manner that merely the lumps were taken out of the water. 

The Haiphong water plant was run by an industrial concern on a contrac- 
tual basis. Chlorination was the responsibility of the municipal authorities. 
For water distribution the municipal system was divided into four general 
sections, each of which received water only 5 hours per day. The contractor 
was responsible for the maintenance of the plant and the municipal lines. 
The plumbing and connections for the consumer were the responsibility of 
the consumer. As a result, each establishment had its own system of well 
or cistern tied into the municipal supply. Consequently, innumerable cross 
connections existed in every installation causing considerable contamination 
of the city systems. Water was never served with a meal; red wine was 
served in its place. The medical party carried canteens, and water was re- 
plenished from the United States ships in the area. 

The sewage system of Haiphong amounted to a system in name only. 
Some of the properties had cesspools and septic tanks, others had the bucket 
collection system, and some, judging from the odors and flies, had no toilet 
facilities. No sewage treatment plant was operated by the city. The sewage 
which inadvertently foiind its way into the system was dumped raw directly 
into the river. Indiscriminate defecation was practiced in the city too, and 
trash and garbage piled upon the sidewalks was a common sight because 
collections were irregular. During periods of excessively heavy rainfall, all 
the main streets became flooded, and sewage flowed out of those yards having 
cesspools or septic tanks. The streets were a long time draining because 
the sewer lines were inadequate and the average height of the city was only 
10 feet above sea level. 

On September 15, Lieutenant J. G. L. R. Kaufman, MSG, with Fleet 
Epidemic Disease Gontrol Unit Number 2 personnel and their equipment, 
arrived and all were installed at the French Naval Base in a room donated 
by Admiral Carville of the French Navy. Working through his "Chef de 
Medicin, " the Admiral supplied the Unit with laboratory space, furniture, 
and even a refrigerator. Without the Admiral's assistance, GTU 90, 8. 6 
would have been unable to satisfactorily perform the laboratory phase of the 
mission. Collection of water samples from all United States ships in the 
area was begun. Golorimetric test kits revealed that the chlorine content 
of all water of the vessels was far too low for safety. Accordingly, the 
personnel of the Unit instructed the ships in proper chlorination techniques. 
A requirement of 1 ppm. of available chlorine was established for a minimum 
of 6 hours contact time before a tank was cut into the potable water systems. 
Colorimeter test kits and 70% calcium hypochlorite were furnished by CTU 
90. 8. 6 to those vessels lacking the materials. 



Medical News Letter, Vol. 27, No. 9 



39 



Stool samples and blood specimens were collected from the refugees, 
taken to the laboratory, and processed. Light traps for the collection of 
insects were placed at different locations on the Franch Naval Base and also 
aboard several ships in the area. The insects were sorted and classified as 
accurately as possible with the available insect identification keys. Snap 
traps and wire traps for live rodents were set; the Norway rat was the only 
species captured. During the rodent study, an interesting discovery was 
made: of all the rats captured, combed, and dissected, none had any evidence 
of external or internal parasitic infestation (louse, mite, or flea). Through 
the liaison previously established with the French Military Medical Personnel, 
blood smears were collected from known malarial patients. 

Stool samples were collected and processed from each American in the 
area who became afflicted with the "Indochina Trots, " a particularly debilitat- 
ing form of diarrhea. Concurrently, the medical officers attached to CTU 
90. 8. 6 also provided medical services for the ships in the area. The few 
cases requiring more adequate facilities were evacuated by helicopter to 
the larger ships anchored in Bai D 'Along. 

Dr. Davis performed exceptionally fine work in establishing liaison 
with the French and Viet-Nam authorities and did much to advance the prestige 
of the Unit through his sincerity, personality, and command of the French 
language. On September 1 5, Lieutenant J . G. T. A. Dooley, MC USNR, arrived 
to relieve Dr. Davis, who returned to the USS Estes for further transfer back 
to the U.S Naval Hospital, Yokosuka. Dr. Dooley was fluent in French and 
eventually became very fluent in Vietnamese; consequently, he was dexterous 
in dealing with the Vietnamese refugees. He was on,e of the last to be evac- 
uated when the area was taken over by the Viet-Minh. The enlisted men 
attached to CTU 90. 8. 6 performed their duties in a most creditable manner, 
demonstrating initiative, enthusiasm, and sedulity in all tasks assigned to 
them. Although living and working conditions were never pleasant, the men 
frequently worked far into the night of their own volition. 

Captain Britten arrived at Haiphong on September 26 and assumed 
position as officer in charge of the Unit. The author departed on October 11 
by air for his permanent duty station on the Staff of Commander, Naval Forces 
Far East at the completion of 2 months TAD on Operation "Passage to Freedom. 

(LCDR E.H. Gleason, MSG USN, PrevMedDiv, BuMed) 

****** 
Pre-employment Examinations of the Low Back 

Roentgen-ray findings in 6523 pre-employment low back examinations 
revealed: congenital anomalies in lumbosacral region, 41. 1%; normal spines, 
39. 93%; wear and tear changes in the lumbosacral joint; 6. 3%; postural Sco- 
liosis, 5.0%; advanced spinal arthritis, 3.3%; structural scoliosis, 1.9%; 



40 



Medical News Letter, Vol. 27, No. 9 



increased lumbar lordosis, 1. 3%; old compression fracture of vertebrae, 



The most frequent congenital defects were malformed lumbosacral 
articulating facets, spina bifida occulta of the first sacral segment and super- 
numerary lumbar vertebrae. Most of these people were unaware of any back 
weakness. 

The incidence of patients seeking treatment for low back pain or dis- 
ability was much higher in those showing congenital anomalies in comparison 
to those having negative x-ray findings. 

There is a real need for further criteria to use as a guide to employ- 
ment and a basis of job placement. (LTS M. Walser, B. J. Duffy Jr. , 
H.W. Griffith, MC USNR: J.A.M.A., 160:856-858, 10 March I956) 

NOTE: The above abstract once again points up the importance of examina- 
tions of the low back. In performing pre-employment examinations of the low 
back, Navy occupational medical doctors should obtain detailed histories, 
make roentgen ray examinations and thorough physical examinations (to in- 
clude inspection, palpation, and notation of any limitation of motion) and 
perform any other tests that may be needed for diagnostic purposes. Where 
this procedure is not practical on a routine basis, it should be mandatory 
at least in filling those jobs which call for heavy lifting. 



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